tb risk assessment & targeted testing: significance in a ... · 12/8/2011 · tb risk...
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TB Risk Assessment & Targeted Testing:
Significance in a Low Incidence Area
Alfred A. Lardizabal, MDNew Jersey Medical School Global
Tuberculosis InstituteDecember 8, 2011
Roanoke, West Virginia
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Reported TB Cases United States, 1982–2010*
*Updated as of July 21, 2011
No.
of C
ases
Year
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Year No. Rate*
2005 14,068 4.8
2006 13,732 4.6
2007 13,286 4.4
2008 12,905 4.2
2009 11,537 3.8
2010 11,182 3.6
*Cases per 100,000. Updated as of July 21, 2011
TB MorbidityUnited States, 2005–2010
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TB Case Rates*United States, 2010
*Cases per 100,000
< 3.6 (2010 national average)>3.6
D.C.
West Virginia
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Latent TB Infection (LTBI)
• Infection with Mycobacterium tuberculosis without manifestations of active disease
– Asymptomatic– Normal or stable chest radiography
• >80% TB disease in the US is due to reactivation of latent infection
• Reactivation is preventable
• TB elimination focuses on targeting people with a high risk of LTBI for screening and treatment
Horsburgh CR Jr. NEJM 2011;364:1441-8
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• Cohort study carried out in Palm Beach County, FL (1997-2001)
• Reactivation rates with LTBI (HIV-) was 0.04 cases/100 person years (0.10 -0.16 in 1950’s)
• After stratification to control for effect of HIV, increased rates of reactivation TB were also seen among persons older than 50
Horsburgh CR Jr. Am J Respir Crit Care Med 2010;182:420-425
Latent TB Infection (LTBI)
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Unique Challenges
• Loss of expertise
• Scarcity of special facilities for prolonged care
• Laboratory costs and decreased proficiency
• Travel in rural areas
• Loss of dedicated funds and personnel
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Eliminating TB in Low-incidence States
• Distinctive strategies needed, based on their specific epidemiologic characteristics, for maintaining skills and resources for finding increasingly rare TB cases, containing outbreaks, and ending transmission
• Capacity for all the essential components of a TB prevention and control program must be retained
MMWR, May 3, 2002/51
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LTBI Diagnosis
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Testing for TB
• Limited by inability to identify Mycobacterium tuberculosis in people with latent infection
• Diagnosis is indirect and based on detecting host immune response to infection
– Tuberculin skin test (TST)– Interferon gamma release assays (IGRA)
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Tuberculin Skin Test
• 4.2% of all tested with TST in US between 1999-2000 had LTBI
• Measures cell-mediated immunity via delayed type hypersensitivity response to tuberculin PPD
• A sensitive test
• Not able to accurately predict risk of reactivation
Risk of reactivation with +TST – 5% Lengthy (4-9 mos.)
treatment
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Tip the Scale: Targeted Testing for LTBI
• Identify groups at highest risk for testing:– More likely to reactivate or progress to disease
once latently infected– High prevalence of latent infection
• Reduce likelihood of screening groups at low risk and lessen false positives
– Low risk groups likely to be exposed in future (e.g., HCW) is one exception
• Decision to test = decision to treat
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High Prevalence of LTBI
• Close contacts of patients with TB disease– Over half lifetime risk of reactivation occurs in 1-2
years post-conversion
• Foreign-born (recent immigrants <5 years)– In one series, 43% of foreign-born cases with TB
disease had no indication for testing by current guidelines, 65% had been in US > 5 years
• Injection drug users
• Homeless
• PrisonersHorsburgh and Rubin, NEJM, 2011;Cain and Macenzie, CID, 2008;Walter et al., CID 2008
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Horsburgh and Rubin, NEJM, 2011
Increased likelihood of progression from LTBI to TB disease
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High-risk Medical Conditions
• Silicosis
• Diabetes (HbA1C >7.7)
• Chronic renal insufficiency
• Malignancy (head/neck, lung, leukemia, lymphoma)
• Weight loss
• Gastrectomy, jejunoileal bypass
• Other epidemiologically defined high-risk groups, may vary based on area
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TST Administration & Interpretation
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nyc.gov/health
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False TST Results
• False positive– BCG vaccination– Nontuberculous mycobacteria infection– Improper administration or interpretation
• False negative– Very young (<6months)– Inability to mount an immune response (e.g., HIV
or TB itself)– Recent infection (<10 weeks since exposure)– Very remote infection– Recent live virus vaccination– Improper administration or interpretation
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TST Do’s and Don’ts
• Do test:– 8-10 weeks after prior negative
TST for a contact– Prior to immunosuppression
• Don’t test:– Previous positive result – <6 weeks after live virus
vaccine (can be done at same time as vaccine)
– Prior severe reaction
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Two Step Testing
Use two step testing for initial skin testing of adults who will be retested periodically
• If first test positive, consider the person infected
• If first test negative, give second test 1-3 weeks later
• If second test positive, consider person infected
• If second test negative, consider person uninfected
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Tuberculin Testing
True Infection vs. Booster Effect (mm induration)
Situ
atio
n
Time 1 week 1 year0
A
B
C
4
4
4
2
12
14
14
14True converter
Boosted response
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Interferon Gamma Release Assays(IGRA)
• Approved by FDA
– QuantiFERON®-TB GOLD
– QFT-GIT
– T-SPOT ®.TB
• In vitro blood test
• Use antigens not found in BCG or most NTM (ESAT-6, CFP-10, TB7.7)
• More specific, less cross-reaction with NTM
• Can cross-react with M. kansasii, M. marinum, M. szulgai
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ESAT-6CFP-10
MitogenControl
TMB
COLOR
Stage 1 Whole Blood Culture
Stage 2 IFN-gamma ELISA
NilControl
QuantiFERON®-TB Gold Method
Incubate overnight IFN-γfrom sensitized
lymphs
Draw blood with heparin
Make 1 ml aliquots & add antigen
Harvest plasma from above settled cells
Measure [ IFN-g ] in ‘Sandwich’ ELISA
IFN-γ IU/ml
OD
450
nm
Standard Curve
Measure OD anddetermine IFN-g levels
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QuantiFERON®-TB Gold In Tube (QFT-GIT)
www.cellestis.com
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QFT-GIT Interpretation
Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection —United States, 2010. MMWR Vol 59, RR-5
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QFT-GIT
Cellestis Package Insert
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T-SPOT®.TB
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T-SPOT®.TB Interpretation
Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection —United States, 2010. MMWR Vol 59, RR-5
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IGRA Sensitivity and Specificity
TST T.-SPOT.TB QFT-GIT
Sensitivity† 95% 91% 84%
Specificity* 85% 88% 99%
Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection —United States, 2010. MMWR Vol 59, RR-5
†Pooled estimate, low incidence countries*Pooled estimate, patients unlikely to have M. tbinfection
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Comparison of IGRAs and TST
• In vitro test
• Specific antigens
• No boosting
• 1 patient visit
• Minimal inter-reader variability
• Results possible in 1 day
• Requires phlebotomy
• May decline in response to
test after treatment
• In vivo test
• Single antigen
• Boosting
• 2 patient visits
• Inter-reader variability
• Results in 2-3 days
• May be more sensitive in detecting remote infections
_____IGRAs________________TST____________
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IGRA Cautions
• Children < 5 years of age
• Immunocompromised
• System in place for blood collection, transport, etc.
• “Wobblers”
• Cost – overcome with structured implementation
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IGRA Indications – 1
• May be used in place of (but not in addition to) a TST in all situations for which CDC recommends tuberculin skin testing
• IGRA preferred– Hard to reach populations (e.g., homeless,
migrant workers) • Only one visit required
– People who have received BCG (either as vaccine or cancer therapy)• TB specificity higher
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IGRA Indications – 2
• Both TST and IGRA may be considered– At high risk for infection or progression (e.g., HIV) – Suspicion for TB disease exists– Further evaluation of positive TST results in
individuals at low risk for infection and progression– Confirming questionable TST results– Other reasons: immediate hypersensitivity to PPD,
convincing high risk patient with strongly positive TST to take LTBI treatment, indeterminate/borderline IGRA
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IGRA Indications – 3
• Use either TST or IGRA – Contacts– Periodic screening for those with occupational
exposure, surveillance programs etc.
• TST preferred– Children < 5 yrs
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IGRA Summary
• IGRAs are a significant advancement because of high specificity and operational advantages to TST
• Like TST, it is not a perfect test. Cases will be missed if relying exclusively on an IGRA result
• Provider and patient misconceptions need to be met with widespread education and access to consultation
• Training, QA and maintaining IGRA proficiency of laboratory are feasible, achievable, and may be preferable to maintaining TST proficiency of thousands of clinic personnel
• Cost-benefit advantage
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LTBI Screening Guidelines
Horsburgh and Rubin, NEJM, 2011
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Priorities in Screening &Treatment of LTBI
• With new tools for the diagnosis and treatment of LTBI, we now have a chance to improve the effectiveness of TB control in the US by focusing on cost-effective priorities
• IGRA was cost saving compared with TST in certain groups
• LTBI screening guidelines could make progress toward TB elimination by screening close contacts, HIV infected, foreign born regardless of time living in the US
Linas BP. Am J Respir Cri Care Med. 2011;184:590-601
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Essential Components for TB Prevention and Control
• Planning and developing policy
• Finding and managing suspected and confirmed TB cases
• Prevention: finding and managing LTBI
• Providing lab and diagnostic services
• Collecting and analyzing data
• Provide consultation, training, and education
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Prevention:Finding and Managing LTBI
– Local epidemiology and results of contact investigations
– Establish partnerships among stakeholders– Financial and political support– Plan strategy carefully and integrate an evaluation
component
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Thank you.